Transcript 21. Pelvic Injuries

Pelvic Trauma
Pelvic Trauma
Lecture Outline
ƒ Associated injuries
ƒ Resuscitation
ƒ Classification
ƒ Example radiographs
Pelvic Trauma
General Considerations
ƒ Pelvis : ? The most important (or perhaps
most favorite) area of the body (since it
houses the sexual organs)
ƒ Pelvic injuries often represent multisystem injuries
ƒ Definitive management may require a
subspecialist orthopedic surgeon
Pelvic Fractures
Epidemiology
ƒ Overall mortality 6 to 19 %
ƒ If hypotensive, mortality 40 to 50 %
ƒ 60 % due to motor vehicle crashes (MVC's)
–Third most common cause of death from MVC's
ƒ 30 % due to falls
ƒ 10 % due to direct crush of pelvis
ƒ 65 % of deaths due to hemorrhage
Immediate Sequelae of Pelvic Trauma
ƒ Massive hemorrhage
ƒ Bony disruption of pelvis
ƒ Vascular interruption (major and minor)
ƒ Urologic injury
ƒ Bowel and vaginal tears or perforations
ƒ Neurologic injury
Massive Hemorrhage
from Pelvic Trauma
ƒ Major cause of death from pelvic fracture (60 to 80 %)
ƒ 50 to 60 % of deaths due primarily to pelvic fracture occur
within first nine hours of hospital admission
ƒ Degree of hemorrhage dependent on fracture type; truly
massive in large posterior fractures
ƒ Retroperitoneum can accomodate large amount of blood
and problem compounded with open fracture
ƒ "Direct open" operative treatment seldom if ever indicated
unless major vascular injury uncontrolled after angiography
(however, surgical placement of external fixator often
indicated & can be done in E.D.)
Pelvic Trauma : Initial Exam
ƒ Local palpation : assess gross instability
ƒ Check both hips ; associated hip Fx common
ƒ Blood at meatus (elicit by "milking" along the urethra first) :
mandates urethrogram and cystogram ; Do not pass foley
first !
ƒ Careful neuro exam
ƒ Vaginal & rectal exam ; if mucosa violated, patient must go
to O.R. for diverting colostomy
ƒ Early external fixator may be needed for unstable Fx ;
another option is compressive external clamp
Pelvic Fractures : Radiology
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Anteroposterior (AP) view shows most fx's
Inlet view : shows inward fx displacement
Outlet view : provides true AP view of sacral foramina
Tangential view : good for sacral fx & sacroiliac (SI)
separation
ƒ Judet views (45 degrees oblique on both sides)
–Help delineate acetabular fx's
ƒ Computed tomography (CT) : more accurate for posterior
arch & acetabular fx's
Standard AP view of pelvis
Standard pelvic inlet view
Standard outlet view of pelvis
Indications for Pelvic Radiography in
the Trauma Patient
ƒ AP view can be used as screening study
–Other film choices on prior slide can then be ordered
based on findings on the AP view
ƒ Should obtain in :
–all major truncal trauma cases (especially if pain
perception altered by head trauma, intoxication, etc.)
with any abdominal pain or findings
–patients with hip pain (may actually show pelvic Fx on
the other side)
Additional Indications for Pelvic
Films for the Trauma Patient
ƒ Ecchymosis or tenderness over any
pelvic bone
ƒ Joint pain with internal or external
rotation of hips
ƒ Abnormal rectal exam
ƒ Abnormal lower extremity neuro exam
ƒ Blood at urethral meatus or hematuria
Pelvic Fractures :
Diagnostic Peritoneal Lavage (DPL)
ƒ May be required to quickly R/O intraabdominal bleeding as cause for shock or
hypotension
ƒ False positive rate higher than for isolated
intraperitoneal injury
ƒ Should use supraumbilical open approach
ƒ Will miss diagnosis if hemorrhage is all
retroperitioneal (so CT is better for Dx if
patient stable enough to obtain scan)
M.A.S.T. (P.A.S.G.)
ƒ Inflation may be helpful to control bleeding
from pelvic fx (inflate abdominal compartment
and leg compartments) if external fixator or
large external clamp not available
ƒ If unable to stabilize patient within 2 hours of
application & suspected arterial bleeder
present, then go to angiography
ƒ If left on too long : risk of compartment
syndrome in legs
Angiography for Pelvic Trauma
ƒ Indicated when hypovolemia persists and other
sources of bleeding ruled out
ƒ Consider early for posterior arch fx's
(associated with greater bleeding)
ƒ Allows Rx by vasopressin infusion or
transcatheter embolization (wire coils or
autologous clot) of bleeding vessel(s)
Classification of Pelvic Fractures
STABLE
Fracture of individual bones : no break in the pelvic ring
Avulsion fractures
anterior superior iliac spine
anterior inferior iliac spine
ischial tuberosity
Fracture of the pubis or ischium (around the obturator foramen)
Fracture of the wing of the ilium (Duverney's fracture)
Fracture of the sacrum
Fracture of the coccyx
Single break in the pelvic ring
Fracture of two ipsilateral rami
Fracture near or subluxation of symphysis pubis
Fracture near or subluxation of sacroiliac joint
Classification of Pelvic Fractures
(cont.)
UNSTABLE : DOUBLE BREAKS IN THE PELVIC RING
Double vertical fracture or dislocation of the pubis (straddle fx)
Double vertical fracture or dislocation of the pelvis(Malgaigne's fx)
Severe multiple fractures (including sacral fracture)
FRACTURES OF THE ACETABULUM
Undisplaced
Displaced
Types of pelvic
fractures
Classification of Pelvic Fractures
by Causative Mechanism
ƒ Lateral compression
–Most common cause ( > 50 %)
–Associated with high incidence of brain injury
ƒ Anteroposterior compression
–30 % of cases
–High incidence of associated thorax and abdominal
injuries
ƒ Vertical shear
–Less common
–Usually from fall from height
Pelvic Avulsion Fractures
ƒ Anterior superior iliac spine avulsion (from
pull from sartorius)
ƒ Anterior inferior iliac spine avulsion (from
pull from rectus femoris)
ƒ Ischial tuberosity avulsion (from pull from
hamstrings)
ƒ Rx : Analgesics, rest, may need temporary
use of crutches ; ORIF rarely only for
professional athletes
Ischial
avulsion
fracture due
to hamstring
or adductor
muscle pull
16 year old sprinter with pain in groin and
buttocks from bilateral ischial apophyses
avulsion fractures
Coccygeal Fractures
ƒ Usually caused by fall in sitting position
ƒ May be caused by childbirth
ƒ No need to reduce transrectally since
reduction usually not maintained due to
muscle pull
ƒ Rx : Analgesics, stool softeners, sacral
dough-nut ; consider coccygectomy if
severe persistent pain (usually if > 1 month)
Sacral Fractures
ƒ Isolated sacral fx's usually transverse (vertical
fx's always associated with Malgaigne fx)
ƒ Do not do bimanual reduction via rectum (may
cause enlargement of presacral hematoma or
conversion to contaminated open fx)
ƒ If neurologic Sx, Rx by surgery
ƒ If no neuro Sx : bed rest, analgesics, sacral
corset
Type II Pelvic Fractures
ƒ Single break in pelvic ring
–Fracture of 2 ipsilateral rami
–Subluxation of symphysis or SI joint
ƒ Usually mechanically stable
ƒ Rx : analgesics, initial bed rest, then
gradual ambulation advanced as
tolerated
Lateral compression injury with overriding pubic symphysis
“Open-book” or anteroposterior compression injury
Type III Fractures
ƒ Double breaks in pelvic ring
ƒ Unstable
ƒ Almost all require surgery
ƒ Are one of criteria for referral to a
trauma center
Straddle Fracture
ƒ Fractures of both pubic rami on both
sides or Fx of both rami on one side &
a symphysis separation
ƒ 1/3 have lower GU tract injury
ƒ 1/3 have abdominal visceral injury
Straddle fracture with
bladder rupture
Inlet view showing
inward displacement of
fracture fragments from
a straddle fracture
Straddle fracture with “teardrop” bladder compressed
by lateral hematomas
Malgaigne Fracture
ƒ Anterior and posterior pelvic ring
fracture
ƒ Anterior : both pubic rami
ƒ Posterior : fx ilium, SI joint separation
or sacral fx (vertical)
Malgaigne Fracture
Associated Injuries
ƒ 50 % have intra-abdominal injury
ƒ 50 % have GU tract injury
ƒ > 25 % have head injury
ƒ > 25 % have chest injury
Malgaigne fracture with diastasis of pubic symphysis and left
S-I joint and left posterior hip dislocation
Vertical shear injury with superior migration of right hemipelvis
Acetabular Fractures
ƒ Posterior lip fx
–Most common
–Associated with posterior hip dislocation
ƒ Central or transverse fx
ƒ Fracture of anterior (iliopubic) column
ƒ Fracture of posterior (ilioischial)
column (Walther fx)
Transverse acetabular fracture (note cystogram shows
intact bladder)
Pelvic ring fracture and right acetabular fracture
Displaced posterior
wall acetabular
fracture
External pelvic
fixator frame
Pelvic Fractures : Summary
ƒ Assess pelvis as part of secondary survey
ƒ Treat associated injuries
ƒ Consider sequence of fluid support :
angiography : M.A.S.T. inflation : surgery
(laparotomy or external fixator +/- plating)
for continued bleeding from pelvic
fractures
ƒ Assess for associated injuries to GU tract,
rectum, and femurs